Health inspection·January 8, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive assessment and quarterly review assessments for one (Resident #1) of four residents were reviewed for comprehensive care plans. The facility failed to review and revise Resident #1's care plan quarterly and after each assessment. This failure could affect residents by placing them at risk for not having their individual needs met. Findings included: Record review of Resident #1's Face Sheet printed 01/07/2025, reflected a [AGE] year-old male who was admitted to the facility initially 09/29/2017 and readmitted on [DATE] with diagnoses to include but not limited to end stage renal disease (gradual loss of kidney function), history of open wound left foot, type 2 diabetes with mellitus with foot ulcer (is a chronic condition that happens when you have persistently high blood sugar levels), peripheral vascular disease (slow and progressive disorder of the blood vessels). Record review of Resident #1's annual MDS, dated [DATE], reflected a BIMS score of 11 which indicated moderate impairment. Review of section GG indicated Resident #1 was dependent on staff for ADL's. Review of section M0150 indicated Resident #1 was at risk for pressure ulcers. Record review of Resident #1s care plan revised 01/9/2024 reflected, Resident #1 resisted care, taking medications, eating food from facility kitchen at times, showers/ADL care and attending dialysis. Resident #1 refused therapy on several occasions. Interventions included encourage as much participation/interaction by the resident as possible during care activities and give clear explanation of all care activities prior to and as they occur. Review of Resident #1's care plan conference revealed the last care plan was held 06/13/2024. Page 1 of 2 676480 676480 01/08/2025 Mesquite Village Wellness & Rehabilitation 825 W. Kearney Street Mesquite, TX 75149

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/07/2024 at 2:17 PM with the Social Worker revealed care plan conferences were conducted every 3 months. The Social Worker stated the last care plan meeting should have been in September however was not completed due to an oversight. The Social Worker stated he was not working at the facility in September however would review resident files to ensure care plan meetings were being held quarterly. The Social Worker stated care plan meetings needed to be completed so that residents or responsible party would be updated on resident care. The Social Workers stated he was working on ensuring care plan conferences were done at the same time as the MDS. Interview on 01/08/2024 at 2:30 PM with the Administrator revealed the Social Worker was responsible for ensuring the care plan meetings were held quarterly. The Administrator stated the care plan meeting was likely missed due to the facility being in transition between Social Workers. The Administrator stated she was not sure if other care plan meetings were missed during that time. The Administrator stated she did not think there was a risk to residents due to care plan meetings not being completed due to any changes of condition being discussed in morning and evening meetings. Review of the policy Care Plans, Comprehensive person- Centered revised December 2016 The Interdisciplinary Team must review and update the care plan. At least quarterly, in conjunction with the required quarterly MDS assessment. 676480 Page 2 of 2